Animal-assisted interventions for improving engagement in mental health services

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1 Animal-assisted interventions for improving engagement in mental health services Alexandra G. Zoller, Erin Flynn, Kevin Morris Submitted to the Coordinating Group of: Crime and Justice Education Disability International Development Nutrition x Social Welfare Methods Knowledge Translation and Implementation Other: Plans to co-register: x No Yes Cochrane O ther Maybe Date submitted: February, 2018 Date revision submitted: April 2018 Approval date: 29 May The Campbell Collaboration

2 Title of the review Animal-assisted interventions for improving engagement in mental health services Background Client engagement has been operationally defined as the client's motivation, involvement, active participation, and adherence to the mental health service that they are undergoing (Tetley et al., 2011; Morris, Fitzpatrick, & Renaud, 2014). Engagement can mean that the client is actively behaviorally, cognitively, or emotionally involved with the clinician, the intervention, or if applicable other participants in a mental health service (Hock et al., 2015). Client engagement in mental health services is an important construct to examine as it has been linked to improved clinical functioning, improved outcomes, and treatment completion (Lees, Proctor, & Fassett 2014; Bamberger et al., 2014; Hock et al., 2015). Generally, interventions utilized to improve engagement have been largely monetary compensations at the end of each therapeutic session or at the completion of the mental health service (Stanley et al., 2016; Wall et al., 2006). The use of animal-assisted interventions (AAIs) as a tool to impact engagement in a mental health service has not been thoroughly researched. Animals have been incorporated into mental health treatment since the 1800s as a tool to facilitate connection and interest between the patient, the clinician, and the therapeutic technique being used (Connor & Miller, 2000). Today, inclusion of animals by health or human service professionals is increasingly common and is associated with positive physical and psychological benefits (Bert et al., 2016; Davis et al., 2015). More specifically, research evidence suggests that inclusion of animals into therapy settings may improve client engagement. For instance, various studies report that direct social interaction among humans is increased in the presence of animals (Beetz, 2017; Corson, Corson, Gwynne, & Arnold, 1977; McNicholas & Collis, 2000). Therapists that use animals in mental health services are seen as less threatening, which can reduce barriers to client engagement (Balluerka, Muela, Amiano, & Caldentey, 2014), prompt clients to be more authentic during therapy (Fine, 2015; Kruger, Trachtenberg, & Serpell, 2004), and boost clients sense of safety (Barlow, Hutchinson, Newton, Grover, & Ward, 2012; Eaton, Hoagwood, Acri, Morrissey, & Peth-Pierce, 2016) and motivation to attend therapy (Lange et al., 2007; Morrison, 2007). AAIs have been theorized to promote client engagement due to this potential to enhance social connection, but this has yet to be examined with rigorous research. This review aims to combine these two constructs and examine the effects of AAIs on engagement in mental health services. Data collected on the effectiveness of various AAIs on engagement will inform decisions to implement AAIs in mental health services. 2 The Campbell Collaboration

3 Objectives To assess the prevalence of existing evidence of AAIs that aim to affect engagement in mental health services. 1. Have AAIs been utilized in mental health services to affect engagement? a. How are these interventions structured and delivered (e.g., procedures, duration, and frequency)? b. How is treatment fidelity monitored? c. What outcomes are measured and, if so, how (e.g., research experiments, qualitative observations)? d. How is engagement operationally defined by these studies? Existing reviews No previous systematic reviews or protocols exist on this particular topic. However, there are systematic reviews that cover very specific aspects of AAIs in mental health treatment and mental health services. Hoagwood et al. (2017) reviewed evidence for animal-assisted therapies for children with or at risk for mental health problems and found that AAT is extremely useful for children, specifically equine-assisted therapy for autism and canineassisted therapy for trauma. Brelsford et al. (2017) focused on AAIs in educational settings and found that AAIs have the potential to create positive impact in classroom settings as long as the animals and children's welfare was taken into account. Bert et al. (2016) utilized 36 articles to determine the benefits and risks of AAIs and found they were suitable and safe for inpatients with varying mental health issues. Iancu et al. (2015) conducted a systematic review that examined the impacts of AAIs on people with mental disorders. This systematic review was unique as it included only interventions that took place in farm settings. Maujean, Pepping, & Kendall (2015) examined the effect of AAIs on clients psychosocial outcomes based on experiments that used randomized controlled trial designs. Another systematic literature review focused on AAIs for treating trauma, focusing specifically on post-traumatic stress disorder, abuse, and veteran affairs (O'Haire, Guérin, & Kirkham, 2015). Davis et al. (2015) inquired about the use of AAIs to treat children with autism spectrum disorder. Selby & Smith-Osborne (2013) focused their review specifically on equine-assisted interventions as an adjunct or complementary therapy. Finally, Virués-Ortega et al. (2012) found that AAT affected elderly populations with psychiatric disorders by improving their social functioning in those with psychiatric disorders and decreasing behavioral disturbances in elderly folks with dementia. The definition of AAIs used in these systematic reviews of the use of an animal to provide therapeutic benefit based on a positive relationship between the client and the animal (Davis et al., 2015, & Maujean, Pepping, & Kendall, 2015) informed our decision to define AAIs as an all-encompassing term that includes, but is not limited to, animal-assisted therapy and animal-assisted activities. With regards to systematic reviews on engagement, Kim, Munson, & McKay (2012) specifically looked at adolescents and young adults engagement in their mental health treatment, as engagement can be difficult with this population. Aggarwal et al., (2016) 3 The Campbell Collaboration

4 reviewed clinician-reported descriptions of communication strategies to improve engagement for racial and ethnic minorities who are seeking care in mental health service settings. Walton et al., (2017) looked at engagement with interventions aimed at changing behavior interventions, and offer the idea that engagement is related to whether the client has the required skills to participate in and cognitively understand the intervention. Intervention Eligible interventions will include the use of an animal in a mental health service setting or in the provision of mental health services to affect or improve engagement. Mental health service settings will be defined as spaces that provide mental health services, including schools, farms, mental health organizations (e.g. community counselling centres or residential treatment settings), and medical organizations (e.g. hospitals or nursing homes). The animal-assisted interventions include any non-human species of animal utilized in any setting that provides mental health services for any period of time. Comparison conditions will include mental health service settings that do not include an animal to affect engagement (e.g., incentive programs) and that use variants of AAIs. Population The population under study will include participants of all ages, races, and ethnicities receiving mental health services in studies from any country that reports their findings in English. Outcomes Primary outcomes 1. Eligible studies included in this review must report outcome(s) related to engagement. These reported outcome(s) will be coded. Study designs This review will include randomized controlled trials (RCTs), quasi-randomized trials, observational studies, mixed methods studies, and qualitative studies. We will include all these to understand the scope of research on this topic. References Aggarwal, N. K., Pieh, M. C., Dixon, L., Guarnaccia, P., Alegría, M., & Lewis-Fernández, R. (2016). Clinician descriptions of communication strategies to improve treatment engagement by racial/ethnic minorities in mental health services: a systematic review. Patient education and counseling, 99(2), The Campbell Collaboration

5 Bamberger, K. T., Coatsworth, J. D., Fosco, G. M., & Ram, N. (2014). Change in participant engagement during a family-based preventive intervention: ups and downs with time and tension. Journal of Family Psychology, 28(6), 811. Bert, F., Gualano, M. R., Camussi, E., Pieve, G., Voglino, G., & Siliquini, R. (2016). Animal assisted intervention: A systematic review of benefits and risks. European Journal of Integrative Medicine, 8(5), Brelsford, V. L., Meints, K., Gee, N. R., & Pfeffer, K. (2017). Animal-Assisted Interventions in the Classroom A Systematic Review. International journal of environmental research and public health, 14(7), 669. Connor, K., & Miller, J. (2000). Animal-assisted therapy: an in-depth look. Dimensions of Critical Care Nursing, 19(3), 20. Davis, T. N., Scalzo, R., Butler, E., Stauffer, M., Farah, Y. N., Perez, S., & Coviello, L. (2015). Animal assisted interventions for children with autism spectrum disorder: A systematic review. Education and Training in Autism and Developmental Disabilities, 50(3), 316. Fine, A. H. (Ed.). (2015). Handbook on animal-assisted therapy: Foundations and guidelines for animal-assisted interventions. Academic press. Hoagwood, K. E., Acri, M., Morrissey, M., & Peth-Pierce, R. (2017). Animal-assisted therapies for youth with or at risk for mental health problems: A systematic review. Applied Developmental Science, 21(1), Hock, R., Priester, M. A., Iachini, A. L., Browne, T., DeHart, D., & Clone, S. (2015). A Review of family engagement measures for adolescent substance use services. Journal of Child and Family Studies, 24(12), Iancu, S. C., Hoogendoorn, A. W., Zweekhorst, M. B., Veltman, D. J., Bunders, J. F., & van Balkom, A. J. (2015). Farm-based interventions for people with mental disorders: A systematic review of literature. Disability and rehabilitation, 37(5), Kim, H., Munson, M. R., & McKay, M. M. (2012). Engagement in mental health treatment among adolescents and young adults: A systematic review. Child and Adolescent Social Work Journal, 29(3), Kruger, K. A., Trachtenberg, S. W., & Serpell, J. A. (2004). Can animals help humans heal? Animal-assisted interventions in adolescent mental health. Center for the Interaction of Animals and Society (CIAS) and University of Pennsylvania School of Veterinary Medicine, Philadelphia, PA. Lees, D., Procter, N., & Fassett, D. (2014). Therapeutic engagement between consumers in suicidal crisis and mental health nurses. International journal of mental health nursing, 23(4), The Campbell Collaboration

6 Maujean, A., Pepping, C. A., & Kendall, E. (2015). A systematic review of randomized controlled trials of animal-assisted therapy on psychosocial outcomes. Anthrozoös, 28(1), Morris, E., Fitzpatrick, M. R., & Renaud, J. (2016). A pan-theoretical conceptualization of client involvement in psychotherapy. Psychotherapy Research, 26(1), O'Haire, M. E., Guérin, N. A., & Kirkham, A. C. (2015). Animal-Assisted Intervention for trauma: a systematic literature review. Frontiers in psychology, 6. Selby, A., & Smith-Osborne, A. (2013). A systematic review of effectiveness of complementary and adjunct therapies and interventions involving equines. Health Psychology, 32(4), 418. Stanley, I. H., Chu, C., Brown, T. A., Sawyer, K. A., & Joiner, T. E. (2016). Improved Clinical Functioning for Patients Receiving Fee Discounts That Reward Treatment Engagement. Journal of clinical psychology, 72(1), Tetley, A., Jinks, M., Huband, N., & Howells, K. (2011). A systematic review of measures of therapeutic engagement in psychosocial and psychological treatment. Journal of Clinical Psychology, 67(9), Virués-Ortega, J., Pastor-Barriuso, R., Castellote, J. M., Población, A., & de Pedro-Cuesta, J. (2012). Effect of animal-assisted therapy on the psychological and functional status of elderly populations and patients with psychiatric disorders: a meta-analysis. Health Psychology Review, 6(2), Wall, J., Mhurchu, C. N., Blakely, T., Rodgers, A., & Wilton, J. (2006). Effectiveness of monetary incentives in modifying dietary behavior: a review of randomized, controlled trials. Nutrition reviews, 64(12), Walton, H., Spector, A., Tombor, I., & Michie, S. (2017). Measures of fidelity of delivery of, and engagement with, complex, face to face health be systematic review of measure quality. British journal of health psychology, 22(4), The Campbell Collaboration

7 Review authors Lead review author: The lead author is the person who develops and coordinates the review team, discusses and assigns roles for individual members of the review team, liaises with the editorial base and takes responsibility for the ongoing updates of the review. Name: Title: Affiliation: Address: City, State, Province or County: Alexandra G. Zoller Research Assistant Institute for Human-Animal Connection, Graduate School of Social Work, University of Denver 2148 South High Street Denver, CO Post code: Country: USA Phone: Co-author(s): Name: Title: Affiliation: Address: City, State, Province or County: Erin Flynn Research Associate Institute for Human-Animal Connection, Graduate School of Social Work, University of Denver 2148 South High Street Denver, CO Post code: Country: USA Phone: Name: Title: Affiliation: Kevin Morris Research Associate Professor Institute for Human-Animal Connection, Graduate School of Social Work, University of Denver 7 The Campbell Collaboration

8 Address: City, State, Province or County: 2148 South High Street Denver, CO Post code: Country: USA Phone: Roles and responsibilities Content: Zoller, Flynn, Morris Systematic review methods: Zoller, Flynn Information retrieval: Zoller, Flynn Statistical analysis: No statistical analysis will be performed Funding No funding is being utilized from external or internal sources for this systematic review. Potential conflicts of interest None to disclose for this review. Preliminary timeframe Date you plan to submit a draft protocol: July 2018 Date you plan to submit a draft review: January The Campbell Collaboration